Introduction

This guide is designed to help you understand and prepare for HQAA’s accreditation process and to provide you with a description of how a typical survey cycle is conducted.

HQAA accreditation can be awarded for up to three-years to those companies that consistently operate with established quality business practices and demonstrate quality and ethical practices throughout their HME operations.

Confidentiality and Disclosure

HQAA considers any information received from your organization as confidential with the exception of your accreditation status, which is information required by the Centers for Medicare and Medicaid Services (when appropriate), and when necessary government licensing organizations and law enforcement agencies. For those companies successfully gaining accreditation, this information is available to the general public through request and accessible on HQAA’s website.

Aggregate data from your organization and others may be shared with outside organizations providing the information is not identifiable to your organization. HQAA’s Business Associate Agreement explains the subject of Protected Health Information and how HQAA adheres to applicable HIPAA rules.

HQAA Process

The HQAA process is an electronic, web-based process that does not overburden you and your company with our paperwork. A personalized approach is taken in a two-prong method that takes you from the beginning of the accreditation process to site survey. HQAA sees the approach as a document review and then the site survey completion. The document review is done with the support of your assigned Accreditation Coach in your personalized Workroom and the site survey is planned with the support of your assigned surveyor.

Document Review - Working with the Coaches

In your Workroom you will find modules of the HQAA Standards that have been assigned to your company, several ways in which to communicate to your coach, and a variety of helpful tools to work through the document review process. Within the Workroom, you will see the required documents to be sent to your assigned Coach. Your Coach will receive, review and assist with your documentation as it is created or exists in your organization. Their main purpose is to ensure that your documentation is the best it can be in relationship to the HQAA standards. The coach’s responsibility and focus is to compare your documentation to the criteria requested in the standard and then communicate to you if it meets the criteria, or make suggestions as to how it can best match. This system of progressive document approval is designed to strengthen your business practices and ultimately improve services to your patients and the bottom line. Each of the standards has its own workroom web page that consistently contains the information that is described below:

Standards

The standards provide guidance as to what operational processes are required, or considered best practices, and to give you insight into what the surveyor uses as a guide to determine your organization’s level of compliance. Your written policies and procedures should accurately reflect your daily business practices.

Evidence of Compliance

The “Evidence” section offers those items, areas, policies, etc. that demonstrate your compliance with the standard. This section is written to give you examples of how you can provide evidence that you are compliant. For example: Evidence of Compliance for cleaning and maintaining equipment could be the cleaning and maintenance policy and an example of a cleaning log. The examples given in Evidence of Compliance do not encompass the entire scope of compliance with a particular standard and can be expressed in an alternative fashion as you or your company feels appropriate.

Examples to Validate

These are suggestions as to how the standard may be observed. Examples to Validate are not mandatory, but rather offered as examples as to how you may demonstrate that you are in compliance with the standard or what a surveyor may look for during a site visit.

Survey Process

Once your organization has reached 100% completion of the online requirements, the HQAA Director of Survey Services is notified and assigns a surveyor to your company. The assigned surveyor is responsible for ensuring that all services you have chosen to be accredited are surveyed. It is the surveyor’s responsibility to review the documentation you submitted to your Workroom and to conduct a telephone interview with you prior to determining the site visit. HQAA surveys are conducted on an unannounced basis within parameters that the surveyor will define for you. The following information outlines, in general terms, how a survey is conducted for a Durable Medical Equipment company.

The Opening Conference

Upon arrival at the organization the HQAA field surveyor(s):

• Meets with the CEO and any designated members of the organization
• Explains the time frames for completion of the survey
• Explains the collaborative or educational components of the survey
• Establishes timeframe/process for patient visits
• Assures the confidentiality of any information provided by the company
• Schedules the Exit Conference

Tour of the Facility

In order to determine your organization ’ s compliance with HQAA ’ s standards and to document the level of compliance, the surveyor tours the facility and reviews pertinent equipment, processes and/or services and interviews key personnel and staff as needed.

Client Visits

The field surveyor makes visits to your patient ’ s residence to observe the organization ’ s compliance with HQAA standards and the products and services provided to patients in the home setting. Determination as to how many of your client’s will be visited will be made on the telephone interview which was described above.

Telephone Surveys

The field surveyor may also perform telephone surveys with customers of your organization during the on-site review if deemed necessary.

Exit Conference

At the conclusion of the on-site survey, the HQAA field surveyor(s) conducts an Exit Conference with the CEO and/or other leaders of the organization. The surveyor:

• Addresses the findings of the on-site survey that relate to the HQAA Standards;
• Discusses the observations of the organization ’ s strengths, deficiencies and his/her recommendations to the Accreditation Review Committee; and
• Gives your organization an opportunity to ask questions or seek clarification of any information, deficiencies or recommendations provided.

Disagreement with Statements of Fact

Your organization can disagree with statements of fact within the surveyor’s written report within 14 days of receiving the Post-Site Survey letter from HQAA’s Director of Quality and Compliance. If no item or items have been challenged in writing within the fourteen day period, the accreditation deficiencies and recommendations will stand as written.

Scoring

Scores for each standard surveyed are compiled as a percentage and tabulated. In most cases, if your organization either complies or partially complies with the majority of the standards, accreditation will be awarded. Standards having partial compliance must be corrected to achieve full compliance. Full compliance is proven through either a focused onsite survey and/or the submission of a Post-survey Outcomes Report.

Accreditation Award

Accreditation is awarded to an organization that has successfully completed the accreditation process .

Accreditation Denied

In the event that an organization has gone through the accreditation process, including follow-up, and has not or cannot successfully comply with HQAA Standards, accreditation will be denied.

Accreditation can be denied for reasons such as, but not limited to:

• Required corrective actions are so numerous that the quality standards are not achievable, or;
• Areas of the organization ’ s operational practices have the potential of compromising patient or employee safety.

If accreditation has been denied, your organization must wait one year before re-applying for accreditation with HQAA. Organizations have the right to appeal the decision of Accreditation Denied by filing an appeal with the Director of Quality and Compliance. HQAA’s Accreditation Review Committee is responsible for awarding or denying Accreditation. The Accreditation Committee reports survey outcomes to HQAA’s Board of Directors.

Follow Up

An organization that has completed the survey process, where deficiencies were observed and recommendations noted, will require corrective actions. Follow-up must be satisfactorily demonstrated prior to being awarded accreditation.

Follow-up can include, but is not limited to:

• The approval of a Post-survey Progress Report in which the organization addresses the corrective actions and recommendations identified by the surveyor;
• A Focused Survey conducted by HQAA in which a return site visit is determined to be in compliance with the standards not met during the initial site survey. The Focused Survey would be performed within two to six months from the previous survey. A focused survey often involves the submission of a Post-survey Progress Report.

Organizations must also prove compliance through the submission of their Post-survey Progress Report. Failing a Focused Survey will result in Accreditation Denied.

Post Accreditation

Upon successfully completing the accreditation process, HQAA will provide your organization a letter of accreditation, a certificate of accreditation, and HQAA logo clings for your vehicles and offices. HQAA will also notify CMS of your successful accreditation by providing them with your organization’s NPI number, demographic information and the product lines receiving accreditation.

Conclusion

Your next step in the accreditation process is to print this Accreditation Guide and the Accreditation Agreement also located on the web page. The Accreditation Agreement document is to be signed and returned to HQAA by fax to 866-676-7977, or scanned and sent by email to curt.mclees@hqaa.org within seven (7) days of submitting your application.

Accreditation should not be a process that begins with an update in your organization and ends when the surveys are completed, but rather becomes an ongoing, fluid process that is woven into the organization’s daily operations. Change is constant in the HME industry and that’s why HQAA will continue to support your organization after the site survey has been completed and you have received your certificate of accreditation. Please continue to call Quality Assistance Center when you have questions at 866.909.4722.